What pre-operative optimisation strategies improve outcomes in BSTTs?

Introduction

A number of pre-operative optimisation strategies have been proposed to improve outcomes in patients undergoing complex cancer resection. Most of these studies involve multi-modality interventions, such as ‘fast track protocols’ to optimise nutritional, analgesia and mobility outcomes and reduce surgical morbidity and/or transfusion requirements.

Other preoperative strategies, such as preoperative embolisation are aimed at reduction of intraoperative blood loss.

There is limited evidence to support the use of targeted pre-operative therapies.

Pre-operative embolisation of bone neoplasms

A limited number of publications describe the use of gelatin microspheres or polyvinyl alcohol particles as pre-operative embolisation strategy for bone neoplasms.[1][2] Whilst well described for palliation of unresectable bone tumours or giant cell tumours of the sacrum, there is limited data to support the use of embolisation pre-operatively for sarcoma. No randomised controlled trials (RCTs) have been conducted comparing the use of embolisation with either no-preoperative intervention or with an alternate modality.

Pre-operative embolisation in retroperitoneal sarcoma

Pre-operative embolisation is sometimes considered prior to resection of large intra-abdominal tumours. The rationale of this approach is to reduce operative blood loss, and facilitate surgical resection. Whilst some data suggests that this approach is safe,[1][2] no RCTs have been conducted to compare the use of embolisation with either no preoperative intervention or with an alternate modality.

Pre-operative imatinib mesylate in dermatofibrosarcoma

Kerob et al conducted a Phase II multicentre study of 25 patients and report a benefit for patients with dermatofibrosarcoma treated with imatinib mesylate.[3] This data, whilst limited, support the consideration of imatinib in the pre-operative setting in non-resectable DFSP or when surgery is difficult or mutilating.